Wednesday, November 15, 2006 - Visit this very nice blog with many good resources

OK ... cutting your leg off is truly an experience ... but one that you can survive. It would seem that dealing with your insurance provider is the greater challenge. If you are struggling with your coverage, the two C-Leg Appeals written to Humana might be of help to you! The first was required to convince them to provide a microprocessor knee ... the second was necessary because of all the needed steps they denied on their response to my first appeal.
My amputation and my C-Leg were provided by Humana. Now that my medical coverage is provided by CIGNA, I have made an effort to get to know their local customer service people. They are my friends and I am grateful for the tremendous service they provide and for their responsiveness to my needs..
The open letter to CIGNA relates to a decision made on the national level which I believe to be detrimental to all amputees. If you agree ... please take time to write your own!
On the lighter side, enjoy my "Top Ten Reasons Why One Leg is Better Than Two" and see what our wonderful family and friends came up with for my personalized license plate!

Friday, November 10, 2006

Conference to discuss problems of wheelchair users begins

`Wheelchairs available in developing countries are not user friendly'
`Wheelchairs in developing countries do not suit the needs of disabled people'
Conference may come out with guidelines and recommendations
BANGALORE: Problems of wheelchair users in developing countries and issues about wheelchair provisions will be the highlight of the "Consensus Conference on Wheelchair for Developing Countries," which began here on Monday.
The conference, organised by Mobility India, was inaugurated by Shobha Nambisan, Chairman and Managing Director, Karnataka State Industrial Investment and Development Corporation.
Speaking at the inauguration, Harold Shangali of the International Society for Prosthetics and Orthotics, and Lloyd Feinberg of USAID, said there was a need to raise awareness about wheelchair users' issues in developing countries.
They said most of the wheelchairs available in developing countries were not tailor-made for the needs of people with disabilities.
There were very few centres in such countries that made wheelchairs according to the requirements of its user, they said. A large number of wheelchairs used in developing countries did not suit the needs of its users because they were donated by agencies located in developed countries.
Therefore, only seven per cent of such wheelchairs were actually used, they said.
The conference, which is on till November 11, will come out with standard guidelines and recommendations on wheelchair provisions, Mr. Shangali said.
The guidelines would be circulated to most organisations in developing countries working in this area, he added.
The conference is supported by ISPO, the World Health Organisation and USAID. Around 100 delegates, including 20 wheelchair users, from various countries are participating in the conference.

Creating a foam Ankle-Foot Orthosis positive model.

Check out this link to see an Ankle Foot Orthosis CAD model being craved on YouTube.Creating a foam Ankle-Foot Orthosis positive model. This has been posted by

Wheelchair news, help and support news

Sometimes you just need to sit down!
Here is a blog full of information on wheelchairs.

Wednesday, November 08, 2006

America Supports You: Military amputees to get free service dogs

Military amputees at Walter Reed Army Medical Center in Washington, D.C. will be able to obtain service dogs to help them become more mobile and independent, according to the American Forces Press Service. The dogs, provided by the Guide Dog Foundation, are trained to help soldiers balance as they learn to walk with artifical limbs, to retrieve dropped items, and in some cases, to serve as a brace for soldiers to lifr themselves. Read more at link above.

Monday, November 06, 2006

Digital Amputations

Surgical therapy:

The primary initial goal in the treatment of traumatic amputations is to evaluate the suitability of the amputated part for replantation. Amputations of the thumb, multiple fingers, the hand at the level of the wrist or distal forearm, and the upper extremity above the elbow should be evaluated for replantation because patients can benefit functionally from replantation of these appendages even if function of the part is less than optimal.

Often, replantation at these levels can achieve good functional outcomes. Replanted single fingers can be stiff and impede the opposition of other fingers to the thumb and overall hand function. Replanted single-finger amputations can achieve better range of motion when the level is distal to the insertion of the flexor digitorum superficialis (May, 1982).

Single-finger replantation can be considered when patients have injuries to other fingers of the same hand; all of these injuries require splint immobilization and rehabilitation that impedes immediate return to work. Accordingly, single-finger replantation can be considered in special circumstances. The surgeon must not become absorbed in the technical challenge of the replantation and neglect the other associated injuries because poorer outcomes and greater financial cost (due to lost wages and cost of hospitalization and therapy) can result.

In performing an amputation, it is important to preserve functional length. For example, an above-elbow arm amputation should be replanted to provide the patient with a functional elbow on which a prosthesis can be fitted, resulting in better function than an above-elbow prosthesis. Durable coverage at the end of an amputation is critical to the function of an amputation. This may necessitate the use of a local flap. Preservation of sensibility on the amputation stump can optimize the usefulness of the remaining appendage.

Sometimes, local flaps can be used to bring sensate tissue to the stump tip. It is important to minimize the risk of painful neuroma formation at the amputation stump and to prevent joint contractures in the treatment of amputations. Some local flaps can pose a risk of joint contracture to the involved finger and adjacent fingers. Use of the delayed groin flap can risk elbow and shoulder joint contractures. Other critical objectives in the treatment of amputations are early return to work and fitting with a prosthesis when possible.

Digital amputations
In performing digital amputations, provide a mobile, stable, painless stump with the least interference from remaining tendon and joint function to provide the most useful amputation stump. The remaining viable skin is conserved because it may be needed to provide durable soft tissue coverage for the amputation stump. When possible, use volar skin for stump coverage because it provides skin that is thicker and more sensate than dorsal skin (Omer, 1978).

There are several local options for tissue rearrangement of volar skin over the amputation stump. These include fillet flaps, volar V-Y flaps, bilateral V-Y flaps, and homodigital island flaps (Wilhelmi, 2002). Dog ears in the acute traumatic amputation should often be left to eliminate tension and to prevent compromising blood flow to the remaining flaps achieving closure; these dog ears disappear over time. If the wound is small, it can be allowed to heal spontaneously by contraction and epithelialization. Wounds smaller than 1 cm can heal spontaneously in a reasonable amount of time. Larger wounds may require a skin graft to heal quicker. Split-thickness grafts can be used for the benefit of wound contraction to result in a smaller area on the tip, which is not normal pulp.

Regarding the treatment of the bone in a digital amputation, the bone under the stump end must be smooth. Remaining bone chips and devitalized bone should be removed. The bone at the stump end can be smoothed by using a rongeur and file. Bone length is not as important as a stump with mobile nonsensitive coverage. The bone of the distal phalanx must be of adequate length to support the nail bed and nail growth (Ennis, 1938; Raitliff, 1969; Thompson, 1963; Chase, 1960). With digital amputations involving the thumb, length is important.

The articular cartilage can be preserved when the amputation occurs at the level of the interphalangeal joint. This articular cartilage can provide a shock pad for trauma and potentially causes less pain under than skin than the bone edges. Whitaker and Graham clinically evaluated the preservation of the articular cartilage with digital amputations and found a better outcome leaving the cartilage on the stump end (Whitaker, 1972). The protruding condyles and anterior aspect of the phalanx may be trimmed to provide a less bulbous stump.

In addressing the nerve at the stump end, it is important to avoid neuroma formation in this location. The nerve end should be in a position away from the stump end or an anticipated point of contact pressure. To minimize the risk for neuroma formation at the stump end, traction neurectomy of the digital nerve should be performed bilaterally for each digital amputation. The nerve is longitudinally distracted in the distal direction and then transected to allow for proximal retraction, leaving the nerve end 1-1.5 cm from the fingertip.

Preservation of a tendon insertion improves the active mobility and function of an amputation stump. Therefore, when possible, tendon insertions should be preserved. However, often the amputation level is proximal to the tendon insertion. The profundus tendon should never be sutured over the bone end or to the extensor because this can result in the quadriga effect. The quadriga effect results in less excursion of adjacent normal fingers because of the common profundus muscle from which all the profundus tendons originate. The amputated finger, which has a tighter profundus tendon, reaches the palm before the other fingers do and results in a weaker grip.

Another complication of tendon imbalance is the lumbrical plus posture, which is the paradoxical extension of the involved finger proximal interphalangeal joint with attempted flexion. This occurs when the profundus tendon is allowed to retract proximally, resulting in a pull on the lumbrical muscle as it originates from the profundus. The lumbricals contribute to metacarpal phalangeal joint flexion and interphalangeal joint extension. This proximal pulling of the profundus pulls the lumbrical tighter to extend the interphalangeal joints paradoxically with attempted flexion (Parkes, 1970). However, this lumbrical plus posture after amputations of the distal interphalangeal joint is rare. Also, adhesions can result; therefore, early motion of the amputated finger is recommended.

The digital arteries should be identified and ligated with small caliber sutures or be cauterized. The visible veins can be cauterized as well. Then the skin is loosely approximated to make sure there is no tension on the skin edges. If there is tension on the skin, the bone may be shortened or local flaps can be used.

When amputations are at the level of the distal phalanx, preservation of the profundus insertion is critical. An intact profundus improves functional contribution of the amputated finger and improves grip strength by providing active flexion at the distal interphalangeal joints in conjunction with the other fingers. Preservation of enough bone to support normal nail growth is perhaps the most crucial predictor of functional length with amputations at this level.

Amputations at the level of the distal interphalangeal joint can be closed over the articular surface of the middle phalanx. Local flaps can be used to provide soft tissue for closure over the middle phalanx if needed. The volar V-Y flap is the standard local flap option for injuries at this level. The volar V-Y flap is fashioned with the apex of the V at the proximal interphalangeal crease. When amputations are through the middle phalanx, preserving the flexor digitorum superficialis insertion is desirable. The flexor digitorum superficialis tendon inserts on the middle third of the middle phalanx. Amputations proximal to the superficialis insertion leave the amputated finger without active motion control at the proximal interphalangeal joint level and only with active motion at the metacarpal phalangeal level.

Amputations at the proximal interphalangeal joint can be closed over the articular surface of the proximal phalanx as are amputations at the distal interphalangeal joint. Amputations at this level can still actively flex at the metacarpal phalangeal joint through the action of the intrinsic muscles. If the amputation is near the metacarpal phalangeal joint, especially in the long and ring fingers, dropping small objects because of the defect can be addressed with finger prosthesis or ray amputation, with or without transposition.

Ray amputations
Index finger ray amputations

The index finger is the most important digit other than the thumb. The index is the primary finger used with the pinch function. If length, sensation, and mobility of the index finger are inadequate, the patient bypasses the index finger to preferentially use the middle finger for pinch functions. In this circumstance, an index stump can impede the function of the middle finger and the overall function of the hand. This is the primary indication for a ray amputation of the index finger.

The level of amputation that makes the index finger a candidate for ray amputation is controversial. Ray amputation of the index finger should not be performed acutely for injuries distal to the metacarpal phalangeal joint unless the spare parts are needed for salvage of other digits, such as the thumb. The remaining index finger may be left during a trial period after the initial injury. If the stump impedes function, it can be converted to a ray amputation electively. However, conversion to a ray amputation can narrow the palm and result in loss of grip strength and pronation strength, justifying a trial with the shorter index finger for laborers.

Murray found that power grip, key pinch, and supination strength are diminished by approximately 20% of normal with index ray amputations (Murray, 1977). Pronation strength is diminished by 50% in the same group of patients. The cosmetic appearance of an index ray amputation is highly acceptable.

In performing an index ray amputation, a dorsal longitudinal incision over the index metacarpal is used in conjunction with a circumferential skin incision at the midproximal phalangeal level. The skin is intentionally left long distally to avoid deficiency that could result in a web space contracture (see Image 1).

The dorsal veins are ligated, and the extensor tendons are transected. The periosteum is scored, and the metacarpal base is transected. The dorsal interosseous and lumbrical muscle tendons are transected. Studies have shown no difference in pinch strength with dorsal interosseous transfer to the second dorsal interosseous muscle; therefore, this technique is not indicated (Murray, 1977). Then, the flexor tendons are divided. The digital arteries and nerves are divided distal to the branches to the palmar skin. Interrupted sutures are used for skin closure. The hand is dressed lightly to allow for early motion.

Middle and ring finger ray amputations

When the middle and ring fingers are amputated at a level near the metacarpal phalangeal level, small objects fall through this area created by the gap of the missing digit. Patients describe difficulty in retrieving change from their pockets. This can be corrected with a ray amputation. However, the loss in grip strength and pronation strength has to be considered before performing ray amputations for these central digits.

The principles of a central ray amputation include removal of the injured finger at the metacarpal base, correcting the rotational deformity, closing the space between the 2 adjacent unamputated fingers, and achieving a satisfactory appearance of the hand. Two techniques of central ray amputation have been described. One involves the transfer of the index finger ray onto the third metacarpal base for the middle finger, and the small finger is transferred to the ring metacarpal base (see Image 2). The other technique involves removing the involved finger at the metacarpal base (see Image 3). The disadvantages of the ray transfer procedure are the requirement for postoperative immobilization and the risk of nonunion. Therefore, the authors' preferred technique for central ray amputation does not involve ray transfer.

The technique of central ray amputation involves the use of a circumferential incision at the midproximal phalanx in conjunction with a dorsal longitudinal incision (see Images 4-18). The dorsal incision is extended through the extensor. The periosteum is scored at the level of the metacarpal base. The metacarpal is transected at its base. Then, the hand is supinated, and the flexor is divided. The neurovascular bundles are divided proximally to avoid neuroma formation at the skin incision. The deep transverse metacarpal ligaments are identified on either side of the volar plate of the involved finger at the metacarpal phalangeal joint.

In transecting the deep transverse metacarpal ligaments, it is essential to preserve enough to attach to each other to minimize gap formation and rotational deformity. Then the ray is amputated. The gap is compressed, and transverse Kirschner (K)–wires are placed through the metacarpals on either side of the ray amputation. Threaded K-wires can help resist sliding of the metacarpals on the K-wires like an accordion. Then, the deep transverse metacarpal ligaments are repaired with 2-0 Ethibond nonabsorbable sutures. The threaded K-wire can help prevent rotational deformity. Active motion is begun early, and the K-wires can be removed at 6 weeks. This technique can be applied to ray amputation of both the middle and the ring fingers (see Image 19). Incomplete closure of the defect and scissoring must be carefully avoided with this technique.

Small finger ray amputations

The small finger plays a role in gripping and hooking objects. Small finger injuries are the most difficult to rehabilitate, and the finger often becomes stiff and immobile, possibly hindering hand function by catching on pockets or other objects. In this circumstance, small finger amputation can be considered. In a laborer, the amputation can be performed at the metacarpal phalangeal joint to remove the flail segment of the proximal phalanx but preserve a broad palm.

If grip strength is not a concern, a more esthetic appearance can be obtained with a small finger ray amputation. In performing a small finger ray amputation, it is important to preserve the insertion of the extensor carpi ulnaris, which inserts on the base of the fifth metacarpal (Swanson, 1964). This procedure is performed through a tennis racquet incision (see Image 20). Moreover, the hypothenar muscles are preserved to cover the gap and provide padding to the ulnar side of the hand (Louis, 1980.

Thumb amputations
The most critical digit to hand function is the thumb. Amputations of the thumb can be debilitating. The level of amputation determines the significance of the functional deficit. In general, the thumb is important as a post to which the fingers oppose. Therefore, in contradistinction to the length of the fingers, the length of the thumb is more important than active motion.

When the thumb tip has been amputated, replantation can provide the patient with the best return to function, even if interphalangeal joint fusion is required. In the event that replantation cannot be performed or is unsuccessful, minimal bone shortening should be performed to provide a smooth bone end over which to close the skin. In fact, the bone should not be removed only to obtain primary skin closure.

A volar rectangular advancement flap (Moberg) should be used to provide soft tissue closure and preserve thumb length (see Images 21-22). The volar advancement flap is raised as a rectangle to include both neurovascular bundles to the metacarpal phalangeal crease of the thumb proximally and is advanced in the distal direction. The Moberg flap can be used to close 1- to 1.5-cm defects (see Image 23). If the amputation level is at or distal to the distal interphalangeal joint, the patient should not experience much functional loss (see Images 24-25). If the patient's amputation level is proximal to the interphalangeal joint, reconstruction with toe transfer or metacarpal lengthening and web space deepening should be considered. If the amputation is at the carpal metacarpal level, pollicization can be considered if the index finger is not injured.

Transcarpal amputations
Transcarpal amputations are rare. Usually, amputations at this level can be replanted and an acceptable return of function is expected. When replantation is unsuccessful or cannot be performed, minimal reconstructive options exist for amputations through the carpus. In general, patients can be fitted with hand prostheses, which provide good cosmetic results. When the wrist supplies active motion, the prosthesis can be operated without an attachment to the elbow or shoulder harness.

Wrist disarticulations
Again, amputations at this level are rare and often can be replanted. Historically, amputations at the below-elbow level have been favored over wrist disarticulations because of the difficulty in wrist prostheses. However, with advances in technology, amputations at this level can be considered. Also, wrist disarticulation level is preferable in children compared to disarticulation below the elbow to preserve growth potential. The advantage of preserving the distal radioulnar joint is that full active pronation and supination can improve the function of the amputated appendage. Therefore, when possible, the distal radioulnar joint should be preserved. Also, the radial styloid flare should be preserved to improve prosthetic suspension. If possible, the palmar skin should be used to cover the stump end to provide thicker and more durable coverage.

Below-elbow amputations
In general, below-elbow amputations should be performed to preserve as much length as possible to preserve maximum pronation and supination. When traumatic amputations are more proximal, even 2 cm of ulnar bone length is sufficient to fit a below-elbow prosthesis. With more proximal amputations, the biceps can be reattached to the ulna at a position that approximates the normal resting length of the muscle. If the biceps is reattached under too much tension, a flexion contracture can result. A soft tissue deficit may require the use of a free flap or local flap to preserve the elbow (Jones, 1994).

Krukenberg procedure
The Krukenberg procedure is mentioned mainly for historical purposes. This operation was first described by Krukenberg in 1917. This procedure involves separating the ulna and radius for below-elbow amputations to provide a pincerlike grasp that is motored by the pronator teres muscle. The indication for this operation is reserved for a blind person undergoing bilateral amputation because it can provide prehension and tactile gnosis.

Elbow disarticulations
Elbow disarticulations are preferred by surgeons and prosthetists over above-elbow amputations because they allow for rotary force transmission over the humerus and the epicondyles provide good support for the prosthesis. The disadvantage of an amputation at this level is that the prosthesis has outside locking hinges, which can damage clothing.

Above-elbow amputations
In traumatic above-elbow amputations, bone resection should be avoided because maintenance of stump length is critical to function. The longer humeral stump has better proximal muscular control and provides a long lever to help maneuver the prosthesis. Even if required for primary closure, bone shortening should be avoided. Split-thickness skin grafting can be considered over the stump end to preserve stump length. It is essential to have bone below the insertion of the pectoralis major. Amputations that are more proximal to the pectoralis are essentially shoulder disarticulations because shoulder motion is lost.

posted by Mr.O&P Student at 8:25 PM 0 comments

Prosthetic Options for the Lower-Limb Amputee Including Immediate and Early Fittings

Figure 1

By Donald Shurr, CPO, PT

In 1922, Wilson reported using plaster casts fitted with wooden or metal pylons for early ambulation. Berlemont, in France and Weiss later in Poland, and Burgess in the United States, reported using this system; only these were applied in the operating room immediately following the surgical procedure. These systems allowed for early weight bearing and quicker time to final prosthesis, as reported by numerous authors. A careful review of these papers reveals most to be anecdotal, but the enthusiasm spread throughout the prosthetic community.

The literature reported several objectives accomplished by the use of these systems. Most of the early systems provided some degree of protection to the fresh wound. Falls were common and remain so today. The thigh-level systems, whether plaster, fiberglass, or later thermoplastics, prevent knee-flexion contractures.

Figure 2

Systems allowing for the attachment of a pylon and prosthetic foot can allow patients to walk partial weight bearing as early as postoperative day two, depending on physician preference, wound status, and other potential complicating factors such as diabetes. The APOPPS™ (Adjustable Post-Operative and Preparatory Prosthetic System) (see figure 1), by FLO-TECH® O&P Systems, Inc. consists of the FLO-TECH-TOR™, which provides protection from trauma caused by scrapes and impact injuries and flexion contractures until the wound heals, the VCSPS™ (preparatory socket), and the UFOS™ (Universal Frame Outer Socket), which accepts both the protective and the preparatory sockets and allows for the attachment of pylon and prosthetic foot components.

Once the wound is healing and the surgeon or managing physician recommends early weight bearing, the Rehab System (FLO-TECH-TOR™ and UFOS™) or the Prep System (VCSPS™ and UFOS™) may be employed. These systems consist of a flexible thermoplastic inner socket (FLO-TECH-TOR™ and VCSPS™) and a more rigid thermoplastic outer socket (UFOS™) (see figure 2).

Other systems available to the certified prosthetist include those made of air bladders as well as the traditional wrap casts and pylons. An advantage of these latter systems is that they are not easily removed by the patient. Lew Schon, MD, has published very detailed reports of the bladder systems and their positive results on many patients with diabetes, using prefabricated prostheses in a prospective study.

Figure 3

As with many other patient care techniques used by prosthetists and orthotists, careful attention to detail often spells the difference between success and failure. Close communication with managing physicians is also important so that each can bring his or her expertise to a successful outcome for the patient.

A second group of patients, albeit a smaller number, with similar needs are those who undergo a transfemoral amputation. Unlike the transtibial amputee, fewer options exist for this group. In our hands these systems are used for the patient with an amputation secondary to a bone or soft tissue tumor and for whom all other options have been rejected. These patients have both length and circumferential differences, making conventional sockets difficult, especially in the early weeks following surgery. This group of patients can ambulate using a partial weight bearing limitation as the prosthesis allows for a safer and less energy costly gait.

FLO-TECH® has a companion system for patients at the transfemoral level, the complete APOPPS-TF™ system. It offers the same protection, adjustability, and weight bearing capability as the TT version. And using the endoskeletal system allows the knees to be substituted as many of this group may be more active than older, dysvascular amputees of the same anatomical level (see figure 3).

Figure 4

The APOPPS™ and the APOPPS-TF™ allow the surgeon to inspect the wound healing daily and the patient to begin walking on day two. Properly instructed patients report an advantage of the FLO-TECH® system is that by simply adjusting the straps and bands on the socket they (the patients) usually do not feel the need to remove the system. As healing occurs, socket modification is done using circumferential straps to tighten the socket, and the addition of stump socks offsets atrophy and volume changes. The VCSPS™ and APOPPS-TF™ are adjustable in AP, ML, and circumference at all levels and as such may provide optimum comfort without the need for additional stump socks, although the cushioning provided by adding more stump socks is a comfort option. Both TT and TF systems are designed with suspension systems to reduce the chance of pistoning and the friction that goes with it. One should expect more pistoning during the early stages of ambulation with the FLO-TECH-TOR™ and the APOPPSTF ™, as these sockets are designed so as not to adversely resist distal migration (see figure 4). The distal pads used in the socket are lively and will return to their original shape immediately after pressure is removed; thus the pads maintain distal contact at all times, prevent pooling of edema distally and promote healing. The pylons used are endoskeletal, allowing the length, tilts, change of components and alignment to be adjustable throughout the life of the system.

FLO-TECH® provides custom fabrication of standard, ischial weight bearing, Symes, knee disarticulation, youth and children’s sockets and systems.

Anyone using these or other systems would be well advised to review the supplement to the Journal of Prosthetics and Orthotics (JPO), Volume 16, Number 3, July 2004. This is the official finding of the consensus conference on Post-Operative Management of the Lower Extremity Amputee published by the American Academy of Orthotists and Prosthetists.

Limb Loss in Older Adults: Improving Outcomes While Reducing Costs

Preoperatively, a prosthetist can provide the surgeon with insight that can help ease the patient's adjustment to a prosthetic limb.

Of the more than 50,000 Americans who are expected to experience a lower-extremity amputation within the next year, more than two-thirds will be older adults. Peripheral vascular disease, with or without diabetes, is the primary causal factor; traumatic injury to the limb is the secondary cause. It is widely agreed that amputation is a surgery of last resort: irreparable loss of the blood supply to a diseased or injured limb is the only absolute indication for amputation.

Amputation is a particularly difficult outcome for older adults and their families. The aging process has already forced physical and mental limitations on many older individuals, and the prospect of prolonged rehabilitation can seem overwhelming. However, advances in the science of prosthetics have led to better long-range outcomes for older adult amputees. Health care professionals are in key positions to encourage these patients and to help them understand that their lifestyle can be restored.

Early Prosthetic Management

Clinical studies1 have demonstrated that early prosthetic management significantly aids in recovery, while simultaneously reducing medical costs. Whenever possible, a prosthetist should be included in the preoperative consultation. While the surgeon will not have long-term patient contact, prosthetic rehabilitation will continue for the rest of the patient's life. Developing a specialized care team at the outset—including the patient, an orthopedic or vascular surgeon, a physiatrist, a prosthetist, a psychologist, a representative of the patient's family, a general care physician, a physical therapist, a podiatrist, a pain management specialist, and a representative of the patient's family—provides the most efficient strategy for case management. There are numerous additional specialists who may be included on this multidisciplinary care team, depending on the patient's specific needs.

Preoperatively, the prosthetist can provide important insight into how the residual limb will interface with the socket of the prosthetic limb. The shape and contour of the distal end of the residual limb are important factors in reducing the potential for painful bone spurs. The manner in which the nerves are severed can help prevent neuromas from forming later. It is much easier for a patient to adjust to a transtibial prosthesis than to a transfemoral prosthesis; therefore, it is important to save the knee when possible. Together, the surgeon and prosthetist can determine the optimal point of amputation as it relates to the fit and function of the prosthesis.

Immediately postop, the prosthetist should apply a limb protector over the surgical dressing. This rigid covering creates a safe environment for the residual limb, protecting it from additional trauma and promoting healing. The limb protector prepares the limb for an initial prosthesis by reducing edema, increasing venous return, and narrowing the risk for infection. These combined attributes often result in early patient discharge, enhancing the cost-containment aspect of the case. The limb protector should be worn during hospitalization and after the patient's return home until the surgical site is completely healed.

Early ambulation encourages healing of the limb and can be tremendously beneficial to the patient's mental outlook As early as the day after surgery, the patient can don a temporary prosthesis and be touch-down weight bearing. The first temporary prosthesis is a preparatory system that is low in cost, averaging around $1,200. The use of immediate postoperative prosthetics (IPOP) results in shorter initial hospital stays, reduced time in skilled nursing facilities, and decreased incidence of return hospitalization.1

The low cost of an IPOP system makes it an attractive option for skilled nursing facilities. Typically, these facilities are reluctant to allow for the cost of a prosthesis to be included in the first 90 days of Medicare Part A; instead, they prefer that the prosthesis fall under Medicare Part B. An inexpensive IPOP can, however, fall under Part A, with the sophisticated final prosthesis being filed under Part B. This approach results in improved across-the-board outcomes: the patient's rehabilitation progresses more quickly; the skilled nursing facility discharges faster; and hospitalization and Medicare costs, return hospital stays, and revision surgeries are reduced.

Prosthetic Advances
The science of prosthetics has advanced dramatically over the past decade. This is due primarily to the evolution of new materials such as urethanes, mineral-based liners, improved silicones, titanium, and carbon fiber. Younger, more athletic amputees have pressed for high-performance legs and feet that enable them to run and sprint. This consumer demand has resulted in intensive research efforts and the development of a new breed of lower-extremity prosthetic limbs.

The very same attributes that athletes are looking for—lightweight, comfortable, responsive—also offer tremendous benefits to older adult amputees. Energy demands and cardiac workload are substantially increased for prosthetic users. Older adults often face limitations with reduced energy and cardiac function even before amputation. This further validates their need for lightweight, dynamic-performance prosthetic limbs.

The first component of the prosthesis is the socket. A greater understanding of the underlying anatomy has led to better surface matching between the residual limb and the socket. Bone, muscle, and vascular contouring greatly enhance circulation in the older adult's residual limb. The new socket materials are much more flexible than the previously used hard plastics—bending, expanding, and contracting along with the residual limb. Today's sockets are total contact, with a form fit that provides a massage-like quality that increases venous return. For the dysvascular amputee, additional physical benefits of the total-contact socket include reduced swelling in the residual limb and decreased pain and discomfort, particularly throbbing sensations. These sockets also allow older adults greater control of the prosthesis without surface damage to the fragile skin of their residual limbs. When walking, as an individual steps on the prosthetic side, the muscles in the residual limb expand and the socket also expands. When the muscles relax in the swing phase of the gait, the socket instantly contracts and clamps back onto the residual limb. This responsive quality of the socket material is known as memory.

Other components of the lower-extremity prosthesis have also been upgraded by new technology. The pylon, which connects the socket to the prosthetic foot, is the means by which weight load is transferred. Today's dynamic pylons emulate the function of the muscles and tendons they are replacing. They allow for flexibility during ambulation and can provide vertical shock absorption and torque absorption. The ankle and foot unit of the prosthesis should be adjustable and provide dynamic response. This combination offers extra cushioning and makes walking easier, thus allowing for an increased activity level and quality of life for the older adult.

A recent study indicates that when wearing a dynamic foot, users of below-knee prosthetics achieve the important goal of symmetry. This means that 50% of their time is spent on the sound foot, and 50% on the prosthetic foot.2 This is of special significance for older adults with diabetes or vascular problems because symmetry balances the stress on both the residual limb and the sound foot. When wearing a nondynamic foot, the ratio shifts and approximately 61% of the time is spent on the sound foot, with the remaining time spent on the prosthetic side.

It is important to provide an older adult with a high-performance prosthetic. These patients require the utmost in comfort and performance in order to thrive. The shock-absorbing qualities that are built into today's prosthetic components result in less injury to the dysvascular amputee's residual limb. This, in turn, minimizes further medical treatment and contains costs associated with injury, infection, pain management, and wound care.

Postamputation Care

Following an amputation, the two most critical points on the older adult's body are the residual limb and the sound foot. Both require extreme care and monitoring by a physician and prosthetist to help prevent pain, infection, and even additional amputation. The residual limb must be kept clean and dry at all times. Unless a suction-type socket is used, older adults should always wear a cushioning sock or liner between the residual limb and the socket. This protects the surface from the direct friction that accompanies ambulation, helping prevent abrasions and breakdown of the skin. Suction sockets touch the skin directly and are recommended primarily for above-knee users and patients with healthy skin on their residual limb. The residual limb should be examined regularly for signs of stress or injury.

Older adults who have lost a limb due to diabetes or vascular problems face a 33% chance of losing their sound limb within 5 years. The best preventive tool is a diabetic foot-care program that includes frequent examination of the foot for any signs of injury. Most older adults will need both a physician and a family member to help them maintain their foot-care program, particularly if a patient has failing eyesight. A podiatrist should be enlisted to clip the patient's toenails. Older adults with peripheral neuropathy need to have their sound foot examined daily by another individual.

Amputation is a difficult outcome for older adults, their families, and the medical care delivery system. With early prosthetic management, however, older adult amputees can benefit from faster recoveries, earlier discharges, and increased rehabilitation potential and independence. Advances in prosthetic design have resulted in greater comfort for the dysvascular amputee and a reduced incidence of injury or infection in the residual limb. In the managed care environment, where the focus is on cost constraint, these techniques deliver the best long-range outcomes for older adult amputees as well as for the care providers, insurance companies, and Medicare plans that serve them.

Kevin Carroll, CP, FAAOP is the vice president of prosthetics for Hanger Prosthetics & Orthotics, Oklahoma City. A practicing prosthetist who specializes in the prosthetic care of older adults, Carroll was recently named a Fellow by the American Academy of Orthotics & Prosthetics.

Wednesday, November 01, 2006

O'Sullivan's running pushes limits to the test

PEARL RIVER — The first time Brian O'Sullivan raced in his specially constructed prosthetic running leg, he took four minutes off his fastest 4-mile time. It was a jump so significant, it cemented in his mind a goal that once might have seemed improbable.

"I came back and told my wife I'm going to run the New York City Marathon," O'Sullivan said.

For her part, Adrienne O'Sullivan had no doubt. She has been watching her husband defy expectations for years, including what she sees as an inexplicable rejection from the New York City Police Department.

"What kept him out of the police department is every preconceived notion that he can't do it," Adrienne said, standing in the living room of their Pearl River home with their 15-month-old son, Kevin, last week.

It will be hard to imagine what O'Sullivan can't do as he crosses the finish line in Central Park on Sunday. The 30-year-old is in the final week of training, and completed a recent 21-mile training run in 3 hours and 27 minutes — an impressive time for anyone.

"The next day I had some shin splints and foot pain," O'Sullivan said. "These are minor injuries that every runner goes through."

O'Sullivan was born with a short thigh muscle, a condition known as proximal focal femur deficiency. The difference in length between his two legs was so great that he wouldn't have walked normally, so he underwent surgeries to remove the shortened limb and was fitted for an artificial leg.

The carbon graphite running leg he now wears, with its spring-loaded curve, bears little resemblance to the prosthetics of his childhood.

"When I was a kid, I was walking around with a wooden leg," he said.

Erik Schaffer is the president of A Step Ahead Prosthetics & Orthotics, the Long Island company that crafted O'Sullivan's leg. Each is individually made by hand, and attaches to the body through suction. O'Sullivan's situation is somewhat unusual in that he has been amputated above the knee and the artificial limb extends up to his hip.

"The materials have really changed," Schaffer said. "The legs are lighter, stronger, more responsive. They require so much less energy for the athlete to move them."

Dick Traum, the first above-the-knee amputee to run the New York City Marathon, now runs the Achilles Track Club. There will be 400 disabled people participating in New York this year with the club, either running or using hand-crank wheelchairs. Traum said the record for an above-the-knee runner is 4:54, set by Brian Froggatt in 1985.

It's a record O'Sullivan is on a pace to beat.

"That is really tremendous," Traum said. "There are probably no more than a dozen above-the-knee amputees who've even tried to do it, because it's very difficult."

O'Sullivan, who wrestled and played high school baseball at Salesian, has always been an athlete. His mother, Dianne, put together a loving tribute to her son that details his swimming at age 2, skiing as a 9-year-old and competing in track and field events while growing up on City Island.

Running a marathon is different in the sheer amount of stress it puts on the body. But O'Sullivan wants to prove something — not just to himself, but to anyone who believes he or she is limited.

"He will also teach the world that a person should not be judged by the way he looks, the same way a book should never be judged by its cover," Dianne O'Sullivan said.

In 1999, after passing the NYPD's written test, O'Sullivan underwent the medical exam that is a precursor to the agility tests. Despite hearing from the doctor that he didn't see a reason not to pass him, O'Sullivan's application was turned down.

With a father and brother in the NYPD, O'Sullivan didn't want any special accommodation, just the chance to take the physical tests required of all candidates. For months he didn't get a reason why, and finally he received an official letter saying it was a medical reason: simply "ortho."

"It's terribly vague," O'Sullivan's attorney, Brian O'Dwyer, said. "To take a kid's future away with one word."

O'Dwyer expects O'Sullivan's discrimination case in state Supreme Court to go to trial in the spring. In the long years that he has tried to break through the blue wall, O'Sullivan has moved on, but stayed in law enforcement. As an investigator for the New York State Crime Victims Board, O'Sullivan interviewed family members of those who died on 9/11. He now has a successful career with another law-enforcement agency, and a family that includes Kevin and 10-year-old Ian.

O'Sullivan's life is different than it was when he first applied to follow in his father's footsteps. He has a degree from the College of New Rochelle, a house and a career track. His own son, Kevin, toddles over to him and pats O'Sullivan's prosthetic leg, something that happens so often it seems part of the bond between father and son.

Maybe it's the pull of family tradition, but part of him wants that opportunity to pass the NYPD's physical test. He still wants to be a cop.

"Stop the nonsense and give me a chance," O'Sullivan said.

In the meantime, as he starts off across the Verrazano-Narrows Bridge this Sunday, O'Sullivan hopes to prove that he is limited only by imagination.

The Journal News (Original publication: October 30, 2006